0312-128 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 q� the B ± ness and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
,� 6358961 C27 C53 10/11/'2(
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby°affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date f • / ' - "Signature of Owner % r
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 1NDEMNITIr INS C6 t Policy No. C./i CIM004:2H7
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
sbate:t'1 .-. it 1. • .L. ",Applicant Z
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and'Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed; under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with.all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
/Signature (Owner/Agent) Date i
BUILDING PERMIT PERM T#
DATE VALUATION A a f1 Pt LOT .0312-3.21:3 TRACT
JOB SITE r" = APN
ADDRESS 152,825 I.ATROMU LAMA _ .
IOWNER
55-531 OAK 11111Z
1,A 0,U1N TIA
USE OF PERMIT
POOL AND/O SPA
CONTRACTOR / DESIGNER / ENGINEER
NAi'•f;i.�l4 J. DUNNN Biba Durms .Deaer t Lmids ap
74-866 UNITON F91.. i%'=_ D
CA .92253 PALM DIESERT CA 92.260
x"/50)773.9523 CDD, E 3549
EWTR.1C FOUINTAIN <190 x/:11 s EX DE.PT H'PFR A.PPItC7VED PI..ANS.2001
CBC.--- .
POOL ANWO VA 3,t�a(►, DC S �t1.
C1�
ES"m'YA TF,rA COS"C O]}' CONST UCTION
PUMMSM9 SUMMARY
COAiMI,YE'TION;!'•'�I'.101.000.418.000 $72.00
.IEC ITRIC A L FEE -- P001, .10'1-000-4213-.000 $tS5.6n
K,il,MBDIO FEE -- PO01. 101-000-419-000. • 227.00
OUB -TOTAL. CC+XOMUC! 109 AND PLAN f".�TF'CK . .
LVE, 33 PRE-PPIM FRO
.T(7TAL L'.1�h,' 111 r1,kI .S ])AM NOW
RECEIPT I DATE 1 I BY ' I D FIN9L�p �G I INSPECT
.a
510W.00
$144.00
$0.00
$1441 cur
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE 7 INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K to Wrap F.A.U.
Framing Compressor
Insulation I I I vpnkc
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
• BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underaround Electric
POOLS - SPAS
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer 0brinection
Fnr�nc��t�kinn
uas aping
Gas Tegt
Appliances -
Final —
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Penn)
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